The difference between gingivitis and periodontitis

Imagine a condition that gradually undermines the very foundation of your smile, often without causing any significant pain or discomfort until the damage becomes considerable. This is periodontitis (also known as periodontal disease), a chronic inflammatory condition that affects the tissues supporting the teeth. Its ‘silent’ nature makes it particularly dangerous: it progresses insidiously, slowly eroding the alveolar bone and the ligaments that keep the teeth firmly anchored, making it the leading cause of tooth loss in adults worldwide, surpassing even tooth decay. A thorough understanding of its nature and how it works is vital for protecting both your oral and general health. 

Definition and classification of periodontal disease

Periodontitis is an infectious inflammatory disease of bacterial origin, characterised by the progressive destruction of the periodontium – a complex of tissues comprising the gums, the periodontal ligament, the root cementum and the alveolar bone. Unlike gingivitis (inflammation of the gums, which is reversible), periodontitis involves irreversible bone loss and the destruction of the dental attachment.

Main classification of periodontal diseases:

Chronic periodontitis: This is the most common form, predominantly seen in adults, but it can develop at any age. It is characterised by a slow to moderate progression of clinical attachment loss (the gums recede from the tooth) and bone loss. The severity correlates with the amount of plaque and tartar present.

Aggressive periodontitis: A rarer form, but one characterised by rapid progression of attachment loss and bone loss. It often affects young people (under 30 years of age), even when oral hygiene appears to be good. There are two main subtypes: Localised Aggressive Periodontitis (LAP), which predominantly affects the incisors and first molars, and Generalised Aggressive Periodontitis (GAP), which involves at least three permanent teeth, other than the incisors and first molars, with extensive destruction and a defective immune response.

Periodontitis as a manifestation of systemic diseases: This category includes cases where periodontitis is a manifestation of a systemic disease, such as uncontrolled diabetes mellitus, haematological disorders such as leukaemia, or certain rare genetic syndromes.

Necrotising periodontal diseases: These are severe forms of periodontitis, characterised by necrosis of the gingival tissues, the periodontal ligament and the alveolar bone. They are often associated with a severely compromised immune system.

Other periodontal conditions: These include periodontal abscesses, endo-periodontal lesions, and developmental or acquired abnormalities of the teeth and gums.

The mechanism of action of periodontal disease

The process of periodontal destruction is a complex phenomenon caused by pathogenic bacteria and the body’s immune response. It is not merely the presence of bacteria, but also the way the body reacts to them, that determines the severity of the disease.

It all begins with the accumulation of bacterial plaque (biofilm) on tooth surfaces and, crucially, below the gum line. This plaque contains complex communities of bacteria, including Gram-negative anaerobic species considered key periodontal pathogens, such as the bacteria of the ‘red complex’: Porphyromonas gingivalis, Tannerella forsythia and Treponema denticola. The toxins and enzymes released by these bacteria irritate the gums.

In response to bacterial irritation, the body’s immune system triggers an inflammatory reaction. Initially, this is protective, attempting to eliminate the bacteria. However, in periodontitis, this response becomes dysfunctional or excessive. Immune cells release inflammatory mediators.

Under the influence of chronic inflammation, the gums begin to pull away from the surface of the tooth, forming a deep space known as a periodontal pocket. This pocket creates an anaerobic environment ideal for the proliferation of aggressive bacteria, which are difficult to remove through routine oral hygiene.

As the bacteria multiply within the pockets and the inflammation persists, the inflammatory mediators begin to actively destroy the periodontal ligament and the alveolar bone that support the tooth. The bone is progressively resorbed, and the ligament disintegrates, losing its ability to hold the tooth firmly in place. This bone loss is irreversible.

This vicious cycle leads to:

• Gingival recession – the gums recede and the roots gradually become exposed.
• Tooth mobility – the teeth begin to wobble.
• Tooth migration – the teeth begin to shift position within the dental arch.
• Irreversible tooth loss – eventually, the tooth, deprived of support, falls out.

In addition to local damage, bacterial by-products and inflammatory mediators can enter the bloodstream via the inflamed blood vessels in the gums. This systemic inflammatory ‘burden’ may contribute to the exacerbation or onset of chronic conditions elsewhere in the body, such as cardiovascular disease and diabetes. 

In the field of oral health, the terms ‘gingivitis’ and ‘periodontitis’ (or periodontal disease) are often used interchangeably, but they represent distinct stages of periodontal disease with very different implications. Understanding the difference between these two conditions is crucial, as gingivitis is essentially a warning sign that can be reversed, whilst periodontitis indicates irreversible damage, requiring more complex treatment. Knowing the specific symptoms of each can guide you towards taking swift and effective action.

From gingivitis to the onset of periodontal disease. Key distinguishing features

The fundamental distinction between gingivitis and periodontitis lies in the extent of the inflammation and the presence or absence of bone loss and loss of dental attachment.

Gingivitis:

• This is the early stage of periodontal disease, an inflammation strictly limited to the gums (the soft tissue surrounding the tooth).
• It is caused almost exclusively by the build-up of bacterial plaque and tartar.
• Reversibility: It is completely reversible through rigorous oral hygiene and regular dental prophylaxis sessions (Airflow and ultrasonic scaling).
• Bone loss/attachment: There is no destruction of the bone or periodontal ligament at this stage.
• Symptoms: Red, swollen, sensitive gums that bleed easily when brushed or flossed.

Periodontitis:

• This is an inflammatory infection that extends beyond the gums to affect the periodontal ligament and the alveolar bone supporting the tooth.
• It is a chronic condition in which the destruction of the supporting tissues is, for the most part, irreversible.
• Reversibility: Although progression can be halted and controlled, lost tissue (particularly bone) cannot regenerate spontaneously.
• Bone loss/attachment loss: The defining feature is bone loss and loss of clinical attachment. Persistent inflammation and the body’s immune response lead to the resorption of the bone anchoring the tooth, creating ‘periodontal pockets’.
• Advanced symptoms: Increased tooth mobility, gum recession, changes in tooth position and, ultimately, tooth loss if left untreated.

Not all cases of gingivitis progress to periodontitis. Factors determining this transition include the individual’s genetic predisposition, a dysfunctional immune response, the presence of specific pathogenic bacteria, and aggravating risk factors such as smoking or uncontrolled diabetes.

Symptoms and diagnosis

Early detection of periodontal problems is essential. It is important to be able to recognise the signs and to see a dentist as soon as possible.

Comparative symptoms:

If you notice any of the warning signs, particularly those indicative of periodontitis, it is essential that you book an appointment with a periodontist.

Differential diagnosis:

• Periodontal probing (using the Florida Probe):  
  • Gingivitis: Normal probing depths of 1–3 mm, with no loss of attachment. Bleeding on probing is a key indicator of active inflammation.
  • Periodontitis: Increased probing depths (>3 mm, often 4–6 mm or more) indicate the formation of periodontal pockets and the presence of periodontitis. Clinical attachment loss is the most important measure and a clear indicator of the destruction of the supporting tissues.
• X-rays:  
  • Gingivitis: Shows no visible bone loss.
  • Periodontitis: Visible bone loss on intraoral periapical and bitewing X-rays is irrefutable evidence of periodontitis. Computed tomography (CBCT) is also used for three-dimensional visualisation of bone structures.
• Microbiological tests: In selected cases of periodontitis, analyses of plaque or saliva samples may be carried out to identify specific pathogenic bacteria.
• Assessment of tooth mobility and furcation involvement: This is carried out exclusively in cases of periodontitis. 

Periodontitis never occurs out of the blue. It is the result of a complex interaction between the presence of certain bacteria, the body’s immune response and a range of predisposing or aggravating factors.

The critical role of biofilm

Although periodontitis is a multifactorial disease, its starting point is always bacterial plaque (dental biofilm). This is a sticky, colourless film that constantly forms on the surface of the teeth. Plaque contains a complex community of microorganisms. Certain Gram-negative anaerobic bacteria are considered primary periodontal pathogens, forming the so-called ‘red complex’: Porphyromonas gingivalis (Pg), Tannerella forsythia (Tf) and Treponema denticola (Td). These bacteria possess specific virulence factors that enable them to evade the host’s immune response, adhere to tissues and initiate destruction.

If bacterial plaque is not removed regularly and effectively, it calcifies, turning into tartar (dental calculus). Tartar is a hard deposit that cannot be removed by routine oral hygiene but requires professional intervention (scaling). Tartar acts as an ideal surface for the further accumulation of bacterial plaque and constantly irritates the gum tissue, perpetuating the inflammatory cycle.

The link between systemic diseases and periodontal inflammation

Beyond the role of local bacteria, periodontal health is profoundly influenced by the body’s general state of health.

• Diabetes mellitus: People with uncontrolled diabetes mellitus are 2–3 times more likely to develop severe periodontitis. Hyperglycaemia affects the function of immune cells and impairs blood microcirculation in the gums. In turn, chronic systemic inflammation caused by active periodontitis can contribute to increased insulin resistance.
• Cardiovascular disease (CVD) and atherosclerosis: Chronic inflammation associated with periodontitis releases a cascade of pro-inflammatory mediators into the bloodstream, which can contribute to systemic inflammation and the progression of atherosclerosis.

Other risk factors for the development of periodontitis

• Smoking: This is the strongest risk factor. Smoking masks gum bleeding, reduces the local immune response, impairs healing and significantly increases the risk of severe periodontitis.
• Genetic predisposition: Certain genetic variations can influence a person’s immune response to bacteria in dental plaque.
• Stress: Chronic stress can compromise immune function.
• Immunosuppressive conditions: Conditions such as HIV/AIDS or immunosuppressive medication weaken the body’s ability to fight periodontal infections.
• Nutritional deficiencies: Severe vitamin deficiencies (e.g. vitamin C, vitamin D) can affect the integrity of gum tissue.
• Certain medicines: Antidepressants, antihistamines and certain blood pressure medicines can affect periodontal health.
• Pregnancy and hormonal fluctuations: These can amplify the gums’ inflammatory response to plaque.
• Traumatic occlusion and poorly fitted dental work: Excessive forces on the teeth or poorly fitted crowns/bridges can exacerbate periodontal damage. 

An accurate diagnosis is the cornerstone of successful treatment for periodontitis. A thorough assessment enables the dentist and periodontist to draw up a personalised treatment plan.

Treatment methods: non-surgical, surgical and adjunctive therapies

The main aim of periodontitis treatment is to eliminate the infection, halt the progression of the disease, regenerate lost tissue where possible, and maintain long-term periodontal health.

1. Non-surgical treatment:
   • Supragingival and subgingival scaling and root planing: This involves the meticulous removal of bacterial plaque and tartar from the tooth surfaces, followed by the smoothing of the root surfaces to eliminate bacterial endotoxins and promote the reattachment of gingival tissues. This can be performed manually or using an ultrasonic scalers.
   • Adjuvant antibiotic therapy: In certain cases, antibiotics applied locally (in pockets) or administered systemically may be used as an adjunct to mechanical therapy, particularly in aggressive or extensive forms of the condition.
2. Surgical treatment:
   • If the non-surgical phase is insufficient, treatment proceeds to the surgical phase. This is necessary to allow direct and visual access to the roots and bone defects, ensuring thorough and effective cleaning (periodontal flaps).
   • Regenerative procedures: Subsequently, regenerative procedures may be carried out with the aim of reconstructing lost supporting tissues. These procedures include bone grafts, guided tissue regeneration using special membranes, the application of proteins derived from the enamel matrix, or the application of blood concentrates (PRF/PRGF) to stimulate tissue healing and regeneration.
3. Adjuvant therapies:
   • Laser therapy: At DENT ESTET clinics, we use laser therapy as part of our periodontal treatment protocol. Dental lasers are used as an adjunct to decontaminate periodontal pockets and to facilitate tissue healing. They can be less invasive and may reduce post-operative discomfort.

Long-term management of periodontal disease

Once the active phase of treatment is complete, the crucial phase of periodontal maintenance begins. This is essential to prevent recurrence and maintain the clinical stability achieved.

This phase involves a periodontal maintenance programme comprising regular scaling appointments and periodic reassessments. The frequency of visits (usually every 3–4 months) is determined by the dentist based on the initial severity of the disease, persistent risk factors and the patient’s ability to maintain effective oral hygiene. These visits include the re-assessment of periodontal pockets, the thorough removal of plaque and tartar, and the provision of guidance and encouragement to the patient regarding oral hygiene. They play an important role in the early identification of any signs of disease recurrence. This programme is vital for preventing the recurrence and progression of tissue destruction. 

Long-term success in managing periodontitis is not limited to the active treatment of the infection, but depends fundamentally on an ongoing commitment to prevention and a rigorous maintenance programme. The ultimate aim is to maintain the gum health that has been achieved and to significantly improve the patient’s quality of life.

Prevention strategies

Prevention is the cornerstone of avoiding the onset of periodontitis or preventing its recurrence once it has been treated:

1. Home oral hygiene: Brushing correctly, twice a day, daily cleaning of the spaces between the teeth using dental floss, interdental brushes or oral irrigators, as well as the use of mouthwash, are essential for removing food debris that leads to the formation of dental plaque.
2. Regular visits to the dentist: Regular visits for a check-up and a prophylaxis session are recommended every 6 months, or more frequently (every 3–4 months) for patients with risk factors or a history of periodontal disease.
3. A healthy lifestyle: Giving up smoking, eating a balanced diet and managing stress are factors that have a significant impact on oral health.
4. Management of chronic conditions: Keeping chronic conditions such as diabetes, cardiovascular disease or autoimmune diseases under control is vital.

Quality of life

Periodontitis, through its clinical manifestations (gum recession, tooth mobility or shifting, tooth loss), can have a significant impact on quality of life. Patients may experience difficulty chewing or speaking, may suffer from tooth sensitivity, or may be affected aesthetically.

Beyond the physical aspects, periodontal disease can cause considerable psychological distress: embarrassment, low self-esteem, and anxiety related to bad breath or tooth loss. These issues can limit social interactions and affect emotional wellbeing.

The dental team’s role is to provide not only clinical treatment, but also emotional support and ongoing education. Once the infection has been controlled and the disease stabilised, procedures to restore aesthetics and function may be considered:

• Gum grafts, to cover exposed roots and improve the appearance of the gums.
• Orthodontic treatment to correct the position of displaced teeth.
• Prosthetic restorations with dental implants where teeth cannot be saved and need to be replaced.

By adopting a rigorous maintenance programme and taking a holistic approach to oral health, patients with periodontitis can lead a normal life, retaining their natural teeth and regaining confidence in their smile, thereby contributing to their general well-being. 

• American Academy of Periodontology. (2018). Periodontal Disease Fact Sheet.
• Carranza, F. A., Takei, H. H., Newman, M. G., & Klokkevold, P. R. (2018). Carranza’s Clinical Periodontology. Elsevier.
• European Federation of Periodontology (EFP). Gum disease.